Structured Exercise Program After Adjuvant Chemotherapy for Colon Cancer: A Cost-Utility Analysis of the CHALLENGE Trial

K Kelvin K.W. Chan (Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada) R Ryan W.K. Chu (Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada) M Matthew C. Cheung (Sunnybrook Health Sciences Centre, Toronto, ON, Canada) K Kerry S. Courneya C Christopher J. O'Callaghan (Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada) J Janette L. Vardy (Faculty of Medicine and Health, University of Sydney, Sydney) S Sharlene Gill (BC Cancer–Vancouver, Vancouver, BC, Canada) C Christine Friedenreich (Departments of Oncology and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada) R Rebecca K.S. Wong (Princess Margaret Cancer Centre, University Health Network, Department of Radiation Oncology, University of Toronto, Toronto) H Haryana M. Dhillon (Faculty of Science, Psycho-Oncology Cooperative Research Group, School of Psychology, University of Sydney, Sydney) V Victoria Coyle (Queen’s University Belfast, Belfast, United Kingdom) N Neil Sun Chua (Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada) D Derek J. Jonker (Ottawa Hospital Research Institute, University of Ottawa, Ottawa) R Ralph M. Meyer (Department of Oncology, McMaster University, Hamilton, ON, Canada) S Shahid Ahmed J John Raymond Zalcberg (Department of Medical Oncology, Alfred Health and School of Public Health, Faculty of Medicine, Monash University, Melbourne, VIC, Australia) S Stephen John Clarke (University of Sydney, Sydney, NSW, Australia) P Patti O'Brien (Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada) P Patricia A. Tang (Arthur J.E. Child Comprehensive Cancer Centre, University of Calgary, Calgary, AB, Canada) R Ralph Wong (CancerCare Manitoba, St. Boniface General Hospital, Winnipeg, Canada) H Howard J. Lim (BC Cancer–Vancouver, Vancouver, BC, Canada) M Matthew E. Burge (Royal Brisbane and Women’s Hospital, Herston, QLD, Australia) M Michael Brundage (Department of Oncology, Queen’s University, Kingston, ON, Canada) A Annette E. Hay (Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada) D Dongsheng Tu (Canadian Cancer Trials Group, Queen’s University, Kingston, ON, Canada) C Christopher M. Booth (Department of Oncology, Queen’s University, Kingston, ON, Canada) K Kate Mahon P Philip Beale L Lisa Horvath D David Goldstein S Stephen Clarke N Nick Pavlakis G Gavin Marx C Connie Diakos M Mustafa Khasraw A Annabel Goodwin P Prunella Blinman W Weng Ng R Ray Asghari W Winston Liauw K Katrin Sjoquist F Fiona Abell S Stephen Ackland A Antonino Bonaventura G Girish Mallesara A Andre Van Der Westhuizen M Maria Aslam L Lindy Turner J James Lynam R Robin Paterson M Mathew George S Sunil Rai S Stephen Begbie K Karen Briscoe L Lorraine Chantrill A Aflah Roohullah A Abiramy Ragunathan S Stephanie Lim S Steven Della-Fiorentina M Melissa Moore B Bhaumik Shah (Fox Chase Cancer Center) S Stephen Brown M Mahesh Iddawela (Monash University Faculty of Medicine, Nursing, and Health Sciences, Melbourne, VIC, Australia) Z Zeewan Wong B Babak Tamjid D David Wyld A Alison M. Hadley M Melissa Eastgate J Jeffrey C.H. Goh N Nimit Singhal T Tim Price C Chris Karapetis S Shawgi Sukumaran T Thomas Ferguson M M. Saleem Raza M Margot Burnell A Anthony J. Reiman S Samantha Gray J James Michael (1Thomas Jefferson University, The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Philadelphia, United States) S Sheldon Rubin M Mohammed Harb M Mahmoud Abdelsalam F Felix Couture J James Biagi A Anna Tomiak C Chris Booth N Nazik Hammad H Heather Ann Ostic T Tim Asmis C Christine Cripps R Rachel Goodwin T Tina Hsu M Michael Vickers R Radhika Yelamanchili (3McMaster University, Medicine, Hamilton, Canada) P Philip F.D. Hughes B Brian Findlay D David Wasserman L Linda M. Lee C Cameron Phillips E Elaine McWhirter B Brandon M. Meyers S Sukhbinder Dhesy-Thind J John Goffin K Kevin Zbuk K Kathryn Towns P Peter James Anglin R Ronald L. Burkes Y Yoo-Joung Ko S Scott Berry S Simron Singh M Mark Doherty K Kristy Wasson M Michael Jonathon Raphael E Eric (Xueyu) Chen M Mark Rother J Jeffrey Myers (2Nemours Children's Health, Wilmington, United States) C Cindy L. Quinton L Leonard Kaizer S Stacey Hubay (Department of Oncology, Grand River Regional Cancer Centre, Kitchener, ON, Canada) E Elaine Bouttell M Mala Bahl A Andrea Molckovsky (Grand River Regional Cancer Centre, Kitchener, ON, Canada) M Mary DeCarolis M Mario Amilcar Valdes M Michael Sanatani (Division of Medical Oncology, Department of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada) S Stephen Welch M Mark D. Vincent M Mary J. MacKenzie K Karin Hahn J Joel Gingerich V Vallerie Gordon M Marianne Krahn P Paul Daeninck V Vamsee Torri C Christina Kim B Benjamin Adam Goldenberg J James T. Paul A A. Saranya Kakumanu H Haji Ibrahim Chalchal M Muhammad Salim O Osama Souied M Mussawar Iqbal K Kimberly M. Hagel N Nayyer Iqbal K Kamal Haider (Saskatoon Cancer Centre, University of Saskatchewan, Saskatoon, Canada) D Dorie-Anna Dueck A Adnan Zaidi S Sasha Lupichuk V Vanessa Krause S Scot Dowden V Vincent Tam (Temple University, Lewis Katz School of Medicine) J Jose Monzon J Jay Easaw R Richard Lee-Ying X Xiaolan Feng K Karen M. King S Sheryl Koski A Andrew G. Scarfe K Karen Mulder M Michael Sawyer J Julie A. Price Hiller J Jennifer Spratlin A Amelie Fontaine (3Cross Cancer Institute & University of Alberta, Edmonton, Canada) J Judith Meza-Junco M Maria Ho K Kelvin Young B Barbara Lynn Melosky H Hagen Kennecke D Daniel John Renouf J Janine Davies J Jonathan M. Loree T Thibault Mazard E Emmanuelle Samalin M Marc Ychou F Fabienne Portales A Ann Thomas R Richard Adams V Vanessa Porter A Alice Dewdney N Nirit Yarom S Stephen Bernard A Autumn McRee K Kathryn Hourdequin S Steven Keteyian (Division of Cardiovascular Medicine, Henry Ford Medical Group, Detroit, Michigan, United States)

Abstract

PURPOSE The phase III CHALLENGE trial (CCTG CO.21) demonstrated that a 3-year structured exercise program (SEP) improved disease-free and overall survival versus health education materials (HEM) in patients with stage III or high-risk stage II colon cancer after surgery and adjuvant chemotherapy. We assessed the cost-effectiveness of the SEP versus HEM. METHODS This prespecified economic evaluation used prospectively collected data from all trial participants (N = 889). The base case adopted the Canadian public payer perspective and included direct health care costs over a 5-year time horizon with a 1.5% discount rate. 36-Item Short Form (SF-36) outcomes were mapped to Short-Form 6-Dimension (SF-6D) utilities using a validated algorithm. Mean costs (2024 in Canadian dollars [CAD]) and effects (life-years [LYs] and quality-adjusted LYs [QALYs]) per participant in each intervention group were used to estimate the incremental costs, incremental LYs/QALYs, incremental cost-effectiveness ratio (ICER, $ CAD/life-year gain [LYG]), and incremental cost-utility ratio ($ CAD/QALY) when applicable. Uncertainty was assessed via bootstrapping (1,000 samples). Notable scenario analyses included a 10-year time horizon and a societal perspective incorporating lost wages because of missed work, measured through the Work Productivity and Activity Impairment questionnaire. RESULTS In the base case, despite an up-front cost of $2,917 (CAD)/participant to provide the SEP, the SEP strategy (total cost: $31,957 (CAD)/participant) was dominant over HEM (total cost: $33,546 (CAD)/participant), being less costly (-$1,589/participant) and more effective (+0.05 LYs/participant; +0.10 QALYs/participant). The SEP was dominant in 53% of bootstrap samples, and 80% fell below a $50,000 (CAD) per QALY willingness-to-pay threshold. Major cost drivers were cancer recurrence or new malignancy and anticancer therapy. Scenario analyses were consistent with the base case. CONCLUSION The SEP was less costly and more effective than HEM. This study can inform payers and health systems with implementation of SEPs in routine care.

Article Details

Volume / Issue Vol. 44, Issue 22
Published August 01, 2026
Pages 2130-2139
ISSN 0732-183X
Publisher Lippincott Williams & Wilkins

Journal Info

Journal of Clinical Oncology

Lippincott Williams & Wilkins

ISSN: 0732-183X Health Sciences

Authors (184)

K

Kelvin K.W. Chan

Odette Cancer Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada

R

Ryan W.K. Chu

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

M

Matthew C. Cheung

Sunnybrook Health Sciences Centre, Toronto, ON, Canada

K

Kerry S. Courneya

C

Christopher J. O'Callaghan

Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada

J

Janette L. Vardy

Faculty of Medicine and Health, University of Sydney, Sydney

S

Sharlene Gill

BC Cancer–Vancouver, Vancouver, BC, Canada

C

Christine Friedenreich

Departments of Oncology and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada

R

Rebecca K.S. Wong

Princess Margaret Cancer Centre, University Health Network, Department of Radiation Oncology, University of Toronto, Toronto

H

Haryana M. Dhillon

Faculty of Science, Psycho-Oncology Cooperative Research Group, School of Psychology, University of Sydney, Sydney

V

Victoria Coyle

Queen’s University Belfast, Belfast, United Kingdom

N

Neil Sun Chua

Cross Cancer Institute, University of Alberta, Edmonton, AB, Canada

D

Derek J. Jonker

Ottawa Hospital Research Institute, University of Ottawa, Ottawa

R

Ralph M. Meyer

Department of Oncology, McMaster University, Hamilton, ON, Canada

S

Shahid Ahmed

J

John Raymond Zalcberg

Department of Medical Oncology, Alfred Health and School of Public Health, Faculty of Medicine, Monash University, Melbourne, VIC, Australia

S

Stephen John Clarke

University of Sydney, Sydney, NSW, Australia

P

Patti O'Brien

Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada

P

Patricia A. Tang

Arthur J.E. Child Comprehensive Cancer Centre, University of Calgary, Calgary, AB, Canada

R

Ralph Wong

CancerCare Manitoba, St. Boniface General Hospital, Winnipeg, Canada

H

Howard J. Lim

BC Cancer–Vancouver, Vancouver, BC, Canada

M

Matthew E. Burge

Royal Brisbane and Women’s Hospital, Herston, QLD, Australia

M

Michael Brundage

Department of Oncology, Queen’s University, Kingston, ON, Canada

A

Annette E. Hay

Canadian Cancer Trials Group, Queen's University, Kingston, ON, Canada

D

Dongsheng Tu

Canadian Cancer Trials Group, Queen’s University, Kingston, ON, Canada

C

Christopher M. Booth

Department of Oncology, Queen’s University, Kingston, ON, Canada

K

Kate Mahon

P

Philip Beale

L

Lisa Horvath

D

David Goldstein

S

Stephen Clarke

N

Nick Pavlakis

G

Gavin Marx

C

Connie Diakos

M

Mustafa Khasraw

A

Annabel Goodwin

P

Prunella Blinman

W

Weng Ng

R

Ray Asghari

W

Winston Liauw

K

Katrin Sjoquist

F

Fiona Abell

S

Stephen Ackland

A

Antonino Bonaventura

G

Girish Mallesara

A

Andre Van Der Westhuizen

M

Maria Aslam

L

Lindy Turner

J

James Lynam

R

Robin Paterson

M

Mathew George

S

Sunil Rai

S

Stephen Begbie

K

Karen Briscoe

L

Lorraine Chantrill

A

Aflah Roohullah

A

Abiramy Ragunathan

S

Stephanie Lim

S

Steven Della-Fiorentina

M

Melissa Moore

B

Bhaumik Shah

Fox Chase Cancer Center

S

Stephen Brown

M

Mahesh Iddawela

Monash University Faculty of Medicine, Nursing, and Health Sciences, Melbourne, VIC, Australia

Z

Zeewan Wong

B

Babak Tamjid

D

David Wyld

A

Alison M. Hadley

M

Melissa Eastgate

J

Jeffrey C.H. Goh

N

Nimit Singhal

T

Tim Price

C

Chris Karapetis

S

Shawgi Sukumaran

T

Thomas Ferguson

M

M. Saleem Raza

M

Margot Burnell

A

Anthony J. Reiman

S

Samantha Gray

J

James Michael

1Thomas Jefferson University, The Cardeza Foundation for Hematologic Research, Center for Hemostasis, Thrombosis and Vascular Biology, Department of Medicine, Philadelphia, United States

S

Sheldon Rubin

M

Mohammed Harb

M

Mahmoud Abdelsalam

F

Felix Couture

J

James Biagi

A

Anna Tomiak

C

Chris Booth

N

Nazik Hammad

H

Heather Ann Ostic

T

Tim Asmis

C

Christine Cripps

R

Rachel Goodwin

T

Tina Hsu

M

Michael Vickers

R

Radhika Yelamanchili

3McMaster University, Medicine, Hamilton, Canada

P

Philip F.D. Hughes

B

Brian Findlay

D

David Wasserman

L

Linda M. Lee

C

Cameron Phillips

E

Elaine McWhirter

B

Brandon M. Meyers

S

Sukhbinder Dhesy-Thind

J

John Goffin

K

Kevin Zbuk

K

Kathryn Towns

P

Peter James Anglin

R

Ronald L. Burkes

Y

Yoo-Joung Ko

S

Scott Berry

S

Simron Singh

M

Mark Doherty

K

Kristy Wasson

M

Michael Jonathon Raphael

E

Eric (Xueyu) Chen

M

Mark Rother

J

Jeffrey Myers

2Nemours Children's Health, Wilmington, United States

C

Cindy L. Quinton

L

Leonard Kaizer

S

Stacey Hubay

Department of Oncology, Grand River Regional Cancer Centre, Kitchener, ON, Canada

E

Elaine Bouttell

M

Mala Bahl

A

Andrea Molckovsky

Grand River Regional Cancer Centre, Kitchener, ON, Canada

M

Mary DeCarolis

M

Mario Amilcar Valdes

M

Michael Sanatani

Division of Medical Oncology, Department of Oncology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada

S

Stephen Welch

M

Mark D. Vincent

M

Mary J. MacKenzie

K

Karin Hahn

J

Joel Gingerich

V

Vallerie Gordon

M

Marianne Krahn

P

Paul Daeninck

V

Vamsee Torri

C

Christina Kim

B

Benjamin Adam Goldenberg

J

James T. Paul

A

A. Saranya Kakumanu

H

Haji Ibrahim Chalchal

M

Muhammad Salim

O

Osama Souied

M

Mussawar Iqbal

K

Kimberly M. Hagel

N

Nayyer Iqbal

K

Kamal Haider

Saskatoon Cancer Centre, University of Saskatchewan, Saskatoon, Canada

D

Dorie-Anna Dueck

A

Adnan Zaidi

S

Sasha Lupichuk

V

Vanessa Krause

S

Scot Dowden

V

Vincent Tam

Temple University, Lewis Katz School of Medicine

J

Jose Monzon

J

Jay Easaw

R

Richard Lee-Ying

X

Xiaolan Feng

K

Karen M. King

S

Sheryl Koski

A

Andrew G. Scarfe

K

Karen Mulder

M

Michael Sawyer

J

Julie A. Price Hiller

J

Jennifer Spratlin

A

Amelie Fontaine

3Cross Cancer Institute & University of Alberta, Edmonton, Canada

J

Judith Meza-Junco

M

Maria Ho

K

Kelvin Young

B

Barbara Lynn Melosky

H

Hagen Kennecke

D

Daniel John Renouf

J

Janine Davies

J

Jonathan M. Loree

T

Thibault Mazard

E

Emmanuelle Samalin

M

Marc Ychou

F

Fabienne Portales

A

Ann Thomas

R

Richard Adams

V

Vanessa Porter

A

Alice Dewdney

N

Nirit Yarom

S

Stephen Bernard

A

Autumn McRee

K

Kathryn Hourdequin

S

Steven Keteyian

Division of Cardiovascular Medicine, Henry Ford Medical Group, Detroit, Michigan, United States